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Osteoporosis Audit


									98                                                                                                                          Osteoporosis ± Audit

                                                                         fracture risk. The pattern of referral to a free, open-access DTX 200
               Osteoporosis ± Audit                                      forearm bone densitometry service introduced at this hospital in
                                                                         January, 1998 has been studied over 24 months. Written noti®cation
                                                                         of introduction of the service was sent to each GP in the district and
                                                                         every local consultant with guidelines for the diagnosis and
                                                                         treatment of OP as well as a simple tick box checklist to
275. The use of peripheral DEXA scanning in primary
                                                                         identify patients at risk. Reminders encouraging referrals were
care ± a case for osteoporosis screening
                                                                         sent to both GPs and consultants regularly. In 1998, between
R.A. Hughes, A. Coutts                                                   January and December, a total of 1391 patients was scanned
Department of Rheumatology, St. Peter's Hospital, Chertsey,              compared to 1099 during the 12 months of 1999. Over 2 years the
Surrey UK                                                                M:F ratio remained unchanged at 1:3:3. The mean age and ranges
The development of `portable' appendicular (peripheral) DXA              were similar in 1998 and 1999 (58 (20±91) to 59 (21±84) years
scanners has prompted a re-evaluation of the role of bone density        respectively). The age distribution was unchanged with 57% below
scanning in a primary care setting as a strategy to increase the         60 years and 40% between 60±79 years in 1998 compared to 53%
recognition of post-menopausal women with osteoporosis. Current          and 42% respectively in 1999. The main sources of referral are
health care policies in the UK and Europe do not support the concept     shown below:-
of screening for osteoporosis in post-menopausal women by DXA                     Rheumatology   Primary Care   Orthopaedic/A&E   General Medicine etc
scanning, favouring an approach centred on identi®cation of
individuals with high risk factors for the development of thin           1998      941 (68%)     271 (19%)      128 (9%)           51 (4%)
bones±early menopause, previous low trauma fracture, family              1999      275 (25%)     545 (49%)      195 (18%)          84 (8%)
                                                                         TOTAL    1216 (49%)     816 (33%)      323 (13%)         135 (5%)
history of osteoporosis, corticosteroid use, de®cient dietary intake
of calcium, lack of exercise of hyperthyroidism.
   As part of the osteoporosis service, a Hologic DTX 200 scanner           In the second year, GP referrals doubled, demonstrating
was used to scan all women between the ages of 60±80 in 5 general        increasing awareness of OP in that sector. However, despite active
practices in West Surrey, a suburban area to the south west of           promotion of the service, the absolute rise in referrals from non-

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London with a predominatly caucasian population. Patients                rheumatological sources, was modest. OP continues to be regarded
identi®ed from practice records were invited to attend for a scan        as a low priority by non-rheumatologists. Despite an emphasis on
in the setting of their own practice surgery and were given an           risk factor assessment, of the referrals made, only 40% were of
osteoporosis health questionnaire to complete on arrival, in order to    patients in the most appropriate age range. These issues must be
identify any of the risk factors above. The results of the scan were     addressed through targeted education of not only primary and
classi®ed as normal (T score -ISD), osteopenic (T score -12.5SD),        secondary care clinicians but also the public.
low risk osteoporotic (T score -2.5SD, Z score -1SD) or high risk
osteoporotic (T score -2.5SD Z score -1SD). In total, 3794 patients
were sent a scan appointment of whom 2699 (71%) attended for a
scan. Non-attenders were equally represented across age groupings
and home address post code districts. Of the 2699 scans, 1085 were       277. Outcome of a direct access bone densitometry service
normal (40.2%), 991 osteopenic (36.7%), 345 low risk osteoporotic        for general practitioners ± are the patients treated?
(12.8%) and 278 high risk osteoporosis (10.3%). This percentage
spread of results was found to be similar in each of the 5 practices.    N.G. Snowise, C.L. Maslen, A.K. Bhalla
Of the 278 women identi®ed as having high risk osteoporosis, only        Royal National Hospital for Rheumatic Diseases, Bath BA1 1RL
130 (46.7%) had one or more of the 7 risk factors in the                 Background: General practitioners (GPs) are able to refer patients
questionnaire. The remaining 148 patients with high risk osteo-          with risk factors for osteoporosis, for DEXA scanning, at this
porosis had no apparent risk factors for osteoporosis other than         hospital. This is a direct access service, where management of the
being post-menopausal women. Of the 278 women with high risk             patients remains in primary care. In the past year, approximately 700
osteoporosis only 45 (16.2%) were receiving any form of bone             scans were performed for GPs, accounting for approximately one
prophylaxis prior to being scanned. All women undergoing a scan          quarter of all the scans undertaken. The aims of the study were to
were subsequently contacted with their results and advice given          determine whether GPs initiate and continue treatment of their
according to the category of diagnosis. All women were given life        patients and if they wish to manage osteoporosis in primary care.
style advice, those with osteopenia or low risk osteoporosis were
                                                                         Method: Postal questionnaires were sent to the GPs of 250
prescribed 1000mg calcium and 400iu vitamin daily and those with
                                                                         consecutive patients who had been referred for a DEXA scan and
high risk osteoporosis wre given an anti-resorptive agent in addition.
                                                                         found to be osteoporotic, on the basis of the T score. A minimum of
These results call into question the policy of identi®cation of
                                                                         1 year had elapsed since the date of the scan.
osteoporotic patients by risk factor identi®cation when cheaper
DXA scanners are now available.                                          Results: Valid replies were received from 220 (87%) questionnaires
                                                                         of whom 202 patients were female, 18 male and the average age 65
                                                                         years. 180 patients were initiated on treatment for osteoporosis by
                                                                         their GP after the scan and 15 patients who were taking medication
276. Uptake of an open access peripheral bone densitometry               before the scan, contiuned the same medication. Overall 195 (89%)
service                                                                  patients were taken medication after their scan. The most widely
J. Galvin, D. Tilley, H. Dyaanand, M. Nisar                              prescribed medication was hormone replacement therapy (HRT) (78
                                                                         patients) or etidronate (49 patients).
Department of Rheumatology, Queen's Hospital, Burton on Trent               After 1 year, 24 patients stopped taking medication altogether (all
DE13 ORB, England                                                        HRT), 32 changed medication (usually to a biphosphonate) and 142
Osteoporosis (OP) has to compete with other health priorities for        were taking the same medication. Overall, 174 (79%) patients were
limited resources in both primany and secondary care. Peripheral         taking medication 1 year after the scan. 87% GPs reported that the
bone (forearm) densitometry is a relatively simple, inexpensive,         management of the patient had been in¯uenced by the scan, helping
operator/patient friendly technique of value in predicting future        to decide whether to initiate or continue treatment.
Osteoporosis ± Audit                                                                                                                        99

   80% GPs felt willing and competent to manage osteoporosis             279. The prevalence of osteoporosis in patients aged 56±80
totally in primary care. 18% GPs stated that one appoinment with a       years attending the A&E or fracture clinic with a fracture of
rheumatologist to initiate treatment would be helpful. No respon-        the distal radius
dents considered that osteoporosis should be largely manageed by a       R. Makadsi, B.A. Teague, H.M. Pratt, W.S. Mitchell
hospital rheumatology department.
                                                                         Department of Rheumatology and General Medicine, Furness
Conclusions: GPs follow up patients who have had osteoporosis            General Hospital, Barrow-in-Furness, Cumbria, LA14 4LF
diagnosed by bone densitometry, initiating treatment in most cases.
Compliance with treatment at 1 year approaches 80%. The bone             Introduction: Post-menopausal women who sustain a wrist fracture
scan helps GPs initiate treatment and most GPs feel that                 are at increased risk of further fractures. The incidence of low bone
osteoporosis should be managed in primary care.                          mineral density (BMD) in these patients is not clear. Nowadays
                                                                         therapies to reduce the increased fracture risk are available.
                                                                         Aims: To determine the presence of osteopenia and increased
                                                                         fracture risk in patients with a fracture of the distal radius by using
                                                                         Quantitative Computerised Tomography (QCT) and Peripheral
278. A survey of general practitioners' opinions on the use              Instantaneous X-ray Imaging (PIXI) to measure BMD. To identify
and value of bone densitometry                                           any predisposing factors for osteoporosis. To compare the effec-
                                                                         tiveness of PIXI with QCT as a quick, cheap and reliable tool in the
L. Radford, A.B. Hassell
                                                                         detection of patients with an increased risk of fracture.
Staffordshire Rheumatology Centre, The Haywood, Burslem, Stoke
                                                                         Method: Female patients aged 56±80 years attending the Fracture
on Trent, ST6 7AG
                                                                         Clinic with a distal fracture were recruited prospectively. Carefully
Introduction: Acess to and appropriate use of bone densitometry          explained informed consent, particularly the use of QCT for the
(BD) is an important aspect of osteoporosis management. Whilst           diagnosis of osteoporosis, was obtained from all patients. Subjects
guidelines have been produced on the indications for BD, little is       were also given an information sheet describing the QCT scan and
known about the approach to it in Primary Care. This exploratory         the National Society for Osteoporosis booklet 'Better Bones for
study assesses general practitioners' (GPs) attitudes on the role of     Life'. In a follow-up clinic patients were informed of the QCT result

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BD, in order to inform service development, and to highlight             and questioned regarding predisposing factors for low bone mass.
potential areas for education.                                           Following QCT, a portable PIXI machine also scanned their heels.
Method: Postal questionnaires were sent to 114 GPs in North              The patients were offered investigation and treatment according to
Staffordshire (40% of the local GP population). Systemic sampling        the BMD result.
(choosing alternate entries from a sampling frame of GPs listed          Results: Forty-®ve patients were recruited to the study with mean
within their practices and respective primary care groups) ensured       age 68.3 years (median 69 years). 11 (24%) had previous fractures.
that a proportionate number of GPs were represented from each            Only one patient had already been diagnosed as having osteoporosis.
PCG and practice setting within the study sample. Issues covered         14 (31%) had had an early menopause, 11 (24%) were heavy
included (1) Service matters ± acess to service, referral pattern, and   smokers, 3 (7%) were on long-term steriods and 2 (4%) had had
waiting times. (2) BD report content and appropriate reporting           prolonged hospitalisation. The QCT results revealed that 27 patients
personnel. (3) The role of BD: respondents were asked to indicate        (60%) were at high risk of fracture, 16 (36%) at moderate risk and
the importance of BD in nine given clinical scenarios. Also they         only 2 patients (4%) had a low fracture risk. When comparing the
were asked to express agreement/disagreement with statements             results of PIXI with QCT, we found that only 17 of the 27 high risk
regarding the usefulness of a BD service in osteoporosis manage-         group matched, 9 were moderate risk and one was low risk. Of the
ment in Primary Care.                                                    16 QCT moderate risk group patients, only 6 were comparable by
Results: 88 (77.19%) GPs from the available sample of 114                PIXI, 4 were high risk and 6 were low risk. The 2 QCT low risk
responded to the questionnaire. There were 64 female and 19              fracture patients were also found to be low risk by PIXI.
male GPs (5 not speci®ed), within 14 single and 73 group                 Conclusion 60% of our patients presenting with a wrist fracture
practices. There was a wide range of GP years of experience and          were judged to have a high probability of subsequent fracture and
BD usage, with 22/56/10 GPs requesting none/1-5/6-10 scans in            36% had a moderate probability. Only 2 patients (4%) had low
the previous 12 months. 86% agreed that they required access to          probability. In the individual patient, when comparing QCT and
BD for effective OP management. 72% felt that "BD saves more             PIXI, only 53% were found to be in the same fracture risk group.
resources than undirected use of treatments". Only 2 felt that BD        Our study would suggest that patients with a wrist fracture should be
would have minimal impact on treatment decisions. 87%                    considered to have ostepenia of osteoporosis. This has follow-up and
expressed a preference for a report with treatment recommenda-           potential treatment implication, the cost of which however, may be
tions from an expert clinician. There was uncertainty regarding          offset by a reduction in future fractures.
the appropriateness of other suitably quali®ed healthcare profes-
sionals producing reports. Long term corticosteroids (89%),
radiological osteopaenia of the spine (79%), permature meno-             280.   Is Colles' fracture indicative of systemic osteoporosis?
pause with no HRT (80%), and strong family history (84%)
were all considered medium or high priority for scanning by a            K.T. Rajan, W.D. Evans, C.C.G. Rhys-Dillon, J. Morgan,
majority of respondents. 77% considered BD to inform HRT                 J.C. Martin, J. Murray
decision with normal menopause as not indicated/low priority.            Departments of Rheumatology and Orthopaedics, Royal
However, 43% felt "chronic low back pain in an otherwise                 Glamorgan Hospital, Llantrisant CF72 8XR, Wales, UK
healthy woman" was a medium or high priority for scanning.               Colles' fracture is relatively common in post-menopausal women
Conclusions: GPs in this survey value BD in their management             and is associated with subsequent more severe fracture such as that
of osteoporosis. Although GPs appear to have embraced some of            of the hip. The purpose of this study was to investigate the incidence
the most important issues, further education and support                 of systemic osteoporosis such as that of the spine and hip in a group
regarding osteoporosis and BD is required in the Primary Care            of female patients with Colles' fracture attending an Accident and
setting. This is particularly relevant with the emergence of             Emergency (A and E) Department of a District General Hospital.
Primary Care Trusts.                                                     We recruited a total of 58 patients presenting over a period of 12
100                                                                                                                       Osteoporosis ± Audit

months of whom 77% had not suffered a previous fracture. Mean             differ in terms of their basic demographic details, reason for referral
(SD) age was 68 (12) years while age at menarche was 13 (1.7)             or ®nal results.
years; 75% were post-menopausal (25.4 (14.5) years post-meno-             Conclusion: The result form we have developed does appear to be
pause) while a further 16% had surgical menopause. Height and             an effective way of delivering results of DXA scans to patients and
weight were 1.56 (0.06) m and 66.0 (13.7) kg respectively. Of these,      treatment is, in general, being commenced appropriately.
58% were cigarette smokers ( 20 per day) while 39% consumed
alcohol; of the latter, 4% admitted having more than 21 units per
week.                                                                     282. The West Midlands Rheumatology Services and
   Bone mineral density (BMD) at the lumbar spine and femoral neck        Training Committee (WMRSTC) Regional Audit: The
was measured by dual energy X-ray absorptiometry (Hologic QDR             prevention and management of corticosteroid induced
4500 Acclaim Elite). Standard deviation scores were calculated using      osteoporosis
the manufacturer's reference data. Lumbar spine BMD was 0.82
(0.16) gcm±2 (giving a Z-score of ±0.2 (1.4) and a T-score of ±2.1        N. Erb, R.C. Duncan, K. Raza, R.S. Situnayake and WMRSTC
(1.5); the corresponding value for the femoral neck was 0.65 (0.14)       The West Midlands Rheumatology Services and Training
gcm±2 (giving a Z-score of ±0.3 (1.2) and a T-score of ±2.4 (1.4)).       Committee (WMRSTC)
Using the World Health Organisation classi®cation scheme, 46%             Background: Osteoporosis is a recognised complication of steroid
were osteoporotic at the lumbar spine and 66% at the femoral neck. In     usage. Although guidelines are available for the prevention and
women with Colles' fracture, BMD at the femoral neck (but not at the      management in this group, studies indicate that only a small
lumbar spine) was signi®cantly reduced compared with an age and           proportion of patients are co-prescribed therapy to prevent bone
sex matched reference population while about 70% may be classi®ed         loss. This audit was conducted to establish the current practice within
as osteoporotic at either site. Our observations suggest that Colles'     Rheumatology Units in the West Midlands Region.
fracture may be indicative of the onset of osteoporosis in a large
proportion of individuals attending A and E departments.                  Methods: Adult Rheumatology patients attending follow-up
                                                                          appointments during a 2 week period in 10 units were assessed
                                                                          using the 1998 National Osteoporosis Society (NOS) Guidance on
                                                                          the prevention and management of corticosteroid induced osteo-

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281. Do patients receive appropriate information and                      porosis. The audit standard was that 80% of eligible patients should
treatment following bone mineral density measurements?                    be on appropriate therapy.
R. Kilding, R, Eastell, N. Peel                                           Results: Of 1855 patients attending follow-up over the audit period,
The Osteoporosis Centre, Northern General Hospital, Herries               1766 (95.2%) had data collected. 235 (13.3%, unit range 5.9%±
Road, Shef®eld S5                                                         24.9%) were currently being prescibed or about to commence
Background: Bone mineral density (BMD) measurement is the                 b 7.5mg daily of oral prednisolone for 6 months or more. Of the 2350
standard approach to assessing fracture risk and enables treatment to     patients taking steroids, 115 (48.9%) had rheumatoid arthritis, 40
be targeted to those individuals at greatest risk of osteoporotic         (17%) connective tissue disease, 30 (12.8%) polymyalgia rheuma-
fracture. However, it is important that the result is communicated        tica, 12 (5.1%) vasculitis, 10 (4.3%) other in¯ammatory arthritis, 12
effectively to the patient and the referring physician. At our centre     (5.1%) other diagnosis, 11 (4.7%) multiple diagnoses and 5 (2.1%)
we offer open access bone densitometry. Patients complete a               diagnosis not stated. DEXA scans were performed in 102 patients
questionnaire at the time of their scan and an individualised report is   (43.4%, unit range 0%±82.9%), of these 53 (52%) had a T score of
sent to the referring physician with an interpretation of the BMD         < ±1.5 at the hip or spine. Of the 235 patients 202 (86%) were
measurement, a risk factor pro®le, and advice about management.           receiving treatment; 111 bisphosphonates, 73 calcium and vitamin D,
                                                                          51 calcium, 17 HRT, 2 calcitriol, 1 testosterone; 53 patients were
Aims: To determine whether these patients subsequently receive            receiving more than one treatment. According to the NOS Guidelines
their results and appropriate treatment.                                  only 148 patients (63%) were receiving appropriate osteoporosis
Methods: 295 patients scanned during February and March 1999              medication. 87 (37%) were inappropriately treated, of which 71
were identi®ed from the departmental database and sent an                 (81.6%) were under treated and 16 (18.4%) were over treated.
explanatory letter and short questionnaire. Non-responders were           Conclusions: Overall, the Region failed to meet the Audit Standard
sent a reminder at one month. Patients responses were then                of 80% of patients being appropriately treated according to the NOS
compared with data from a questionnaire completed prior to the            Guidelines. There was marked variation between the Units in terms of
scan and their results form.                                              percentage of patients receiving steroids, having DEXA scans and
Results: 243 (82%) patients responded. Of these 232 patients were         being appropriately treated for steroid induced osteoporosis. The
analysed, 11 (3%) were found to have attended for follow-up scans         results have been circulated to the participating units and the
and were therefore excluded, result forms for 4 (1%) were                 WMRSTC are currently addressing unit variations. We plan to close
unavailable for analysis. 199 females and 29 males with an age            the loop by re-auditing in 2 years.
range 17-84 years (median 58 years). The most common reason for
referral was long-term steriod use (31%). 199 (87%) patients had
received results, 174 (87%) were able to recall the result. 64% of        283.   Who should treat Paget's disease of bone?
these patients correctly recalled their result when compared with the     P.L. Selby1, M. McCallum2, S.H. Ralston3
true result, giving a Kappa score =0.43 (95% CI 0.32±0.54). Of the        1
77 (34%) patients commencing new treatment as a result of the scan,        University of Manchester Musculoskeletal Research Group,
40 (70%) commenced treatment as advised and 128 (78%) of the              Manchester Royal In®rmary, Manchester, M13 9WL; 2National
164 patients who did not need to start treatment, did not commence        Association for the Relief of Paget's Disease, Walkden,
therapy, correlation of treatment advised with treatment commenced        Manchester, M28 3HH and 3Department of Medicine and
gives a Kappa score of 0.43 (95% CI 0.3±0.56). At one year 61             Therapeutics, University of Aberdeen, Foresterhill, Aberdeen,
(79%) patients starting new treatment as a result of their DXA scan       AB25 2ZD
were still taking medication. 79 (35%) recorded receiving speci®c         Background: In common with many metabolic bone diseases,
lifestyle advice and the greatest disparity was seen with patients        Paget's disease is managed by physicians from a variety of different
failing to recall advice to stop smoking. Non-responders did not          specialities. It is unknown whether the specialist background of the
Osteoarthritis ± Basic Science                                                                                                               101

treating physician has any in¯uence on the type of care offered to        18% failed to improve. Of those who received calcitonin 36% failed
patients.                                                                 to improve. 50% of patients referred to the pain team failed to show
Methods: Questionnaires were sent to a variety of different               improvement.
physicians treating patients with Paget's disease of bone. In addition    Conclusions: Trauma is the inciting factor in most patients with
to speciality, these recorded the number of patients seen, the types of   RSD of the ankle/foot. Thermography and bone scintigraphy appear
treatment offered, and the perceived indications for treatment.           to be the most sensitive diagnostic investigations. Intravenous
Results: Of the 247 replies received 215 (87%) said that they treated     pamidronate apears to be ef®cacious in the treatment of RSD of the
patients with Paget's disease. These comprised 173 (80%)                  ankle/foot, although a randomised, controlled study in required to
rheumatologists, 32 (15%) endocrinologists, and 10 (5%) other             assess this further. The stage of disease at presentation may be
specialists. The median number of new patients seen annually was 6        important in predicting poor outcome.
and the median number of follow up patients was 12, this did not
differ between specialities.
   The treatment of choice for both groups was pamidronate, offered
by 77% rheumatologists and 75% endocrinologists; tiludronate was
offered by 41% rheumatologists and 63% endocrinologists (p=0.03);
and etidronate was offered by 43% rheumatologists and 57%
                                                                                  Osteoarthritis ± Basic Science
endocrinologists (p=0.18). Calcitonin was still used by 23%
rheumatologists and 25% endocrinologists (p=0.82). No physician
used plicamycin. There was no difference in treatment choice
between those physicians who saw more than 10 new patients per            285. The use of confocal laser scanning microscopy and
year and those who saw fewer.                                             image analysis to study connective tissue cells
   The main indication for treatment was pain (mean score 4.8T0.6)        P. G. Bush1, C. I. Adams2, D. L. Gardner1, A. C. Hall1
followed by fracture (3.9T1.6), deafness (3.14T1.8), and heart            1
                                                                           Department of Biomedical Sciences, Hugh Robson Building,
failure (3.4T1.9). There was no difference in treatment indications       George Square, Edinburgh EH8 9XD, 2Department of
between speciality or between those who saw more or less patients.

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                                                                          Orthopaedic Surgery, Princess Margaret Rose Hospital,
Conclusions: Although endocrinologists may be more prepared to            Frogston Road West, Edinburgh EH10 7ED
offer oral treatment for Paget's disease there are no substantial         Background: Connective tissue cells play an essential role in the
differences between treatment practices between rheumatologists           turnover (i.e. synthesis/degradation) of the extracellular matrix
and endocrinologists in their approach to treating Paget's disease.       (ECM). Studying their physiology within this complex environment
Therefore, the speciality of the physician treating Paget's disease       is dif®cult, but essential if the underlying causes of connective tissue
appears to be of little importance.                                       failure (e.g. as in osteoarthritis, OA) are to be elucidated. This study
                                                                          was aimed at developing the method of CLSM for visualising the
                                                                          morphology and volume of living chondrocytes within their native
                                                                          Methods: Articular cartilage was obtained from a range of sources
284. A retrospective, observational study of patients with                (human normal and OA, bovine, equine, avian) and excised with
re¯ex sympathetic dystrophy (RSD) of the ankle/foot                       underlying bone attachment. Explants were then incubated in
A.T. Marshall, A.J. Crisp                                                 physiological culture medium containing calcein-AM and propi-
Department of Rheumatology, Addenbrooke's Hospital, Hills                 dium iodide (5 mM each) to ¯uorescently-labeled living and dead
Road, Cambridge, CB2 2QQ, United Kingdom                                  cells respectively. An upright Leica TCS-NT confocal laser
                                                                          scanning microscope (CLSM) ®tted with Q63 immersion objective
Background: RSD is a poorly understood condition which results in
                                                                          was used to acquire serial optical sections typically of 1mm.
localised bone loss, associated with pain, swelling and vasomotor
                                                                          Quantitative measures of cell volume were performed using
disturbance. The pathophysiology remains unclear and there is no
                                                                          calibrated ¯uorescent spheres. Chondrocyte morphology was
universally accepted treatment. The epidemiology also remains to be
                                                                          visualised and volume determined using Bitplane Imaris and
clari®ed. Three stages of the disease are recognised, stage one
                                                                          VoxelShopPro software.
encompassing early disease and stage three late disease.
                                                                          Results: Accurate determination of chondrocyte volume/morphol-
Aims: This observational study aims to clarify the demographic
                                                                          ogy of chondrocytes to a depth of ~50 mm fron the surface was
details of patients with RSD of the ankle/foot, which investigations
                                                                          possible, however beyond this there was a rapid decrease in the
were the most useful diagnostically, and then compare outcome
                                                                          accuracy of the measurements. De®nition of the membrane edge by
following different treatment regimens.
                                                                          varying the threshold was found to be a key step for identifying the
Methods: All patients with RSD of the ankle/foot that presented           detailed morphology and volume of chondrocytes with a value of
over a ten year period to the Department of Rheumatology, were            40% being optimal. The volume of chondrocytes within super®cial,
identi®ed. Details of history, demographic details and investigations     mid and deep zones of healthy human cartilage from the tibial
were recorded, as were treatment and outcome of each patient.             plateaux were 396T58, 522T98 and 590T21 mm3 respectively
Treatment options included subcutaneous calcitonin, intravenous           (means T s.e.m. for n=5 experiments on b100 cells in each zone).
pamidronate infusion (90mg), and intervention by the pain team, or        The volume of chondrocytes within the mid-zone of mildly OA
a combination of these, and all patients received two weeks of            cartilage was elevated (678T67 mm3; n=5; 75 cells). Furthermore,
inpatient physiotherapy.                                                  by careful use of the thresholding routine, cellular `processes' of
Results: 29 patients were identi®ed (17 right foot, 12 left). 3 later     ~1 mm diam. extending away from the cell body for up to ~20 mm
had a recurrence in the opposite foot. 20 patients were female and 9      were frequently observed (~30% of the cell population), whereas
male. Female age range 22±77 (mean 55, median 58) and male 13±            they were only rarely (<5%) evident in `normal' cartilage.
66 (mean 39, median 36). 23 had a history of trauma (79%).                Conclusions: This technique permitted the accurate visualisation
Thermography was diagnostic in 75%, plain radiographs in 66% and          and computation of the volume and morphology of relatively
bone scintigraphy in 72%. Of those who received pamidronate, only         unperturbed living cells within their complex ECM. Studies on the

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